Skip Navigation LinksHome > April 2009 - Volume 39 - Issue 4 > Joint Optimization: Merging a New Culture With a New Physica...
Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e31819c9b95
Departments: Health Facility Design

Joint Optimization: Merging a New Culture With a New Physical Environment

Stichler, Jaynelle F. DNSc, RN, FACHE, FAAN; Ecoff, Laurie PhD, RN, NEA-BC

Free Access
Article Outline
Collapse Box

Author Information

Authors' Affiliations: Associate Professor, San Diego State University, and Coeditor, HERD Journal, School of Nursing, San Diego, California (Dr Stichler); and Director of Research, Education, and Professional Practice, Sharp Memorial Hospital (Dr Ecoff), San Diego, California.

Corresponding author: Dr Stichler, San Diego State University, PO Box 28278, San Diego, CA 92198 (

Collapse Box


Nearly $200 billion of healthcare construction is expected by the year 2015, and nurse leaders must expand their knowledge and capabilities in healthcare design. This bimonthly department prepares nurse leaders to use the evidence-based design process to ensure that new, expanded, and renovated hospitals facilitate optimal patient outcomes, enhance the work environment for healthcare providers, and improve organizational performance. In this article, the authors discuss the concept of joint optimization of merging organizational culture with a new hospital facility.

Transformational change is life altering, cutting across the grain (trans) and creating a new and sustaining form.1 The concept of transformational change came to mind after we toured the new Stephen Birch Healthcare Center at Sharp Memorial Hospital. The tour was more than an orientation to the new facility for leadership staff; it was also a deeply moving and transforming experience. Small charms, symbols of the cultural change, were given to participants at each stop in the tour-an apple symbolizing health, a small globe symbolizing a world of possibilities, a heart symbolizing love and compassion for all humankind, an acorn symbolizing hospitality, and a symbol of peace that is the result of a mind, body, and spirit at rest. An enactment of Beethoven in character symbolized that there are no limits to our creativity and that by working together in harmony, we can create a symphony.

The experience had been carefully planned and orchestrated by organizational staff and leaders who volunteered to write the script and create an experience that would culminate in a personal commitment from all of Sharp's leaders to create and ensure a truly healing environment for patients and providers in the new facility. The new facility not only represented a change in the place where care would be provided but also would be the catalyst for transforming the philosophy that would guide all aspects of care and would compel providers to act in healing ways to create a truly healing environment.

The joint optimization process of merging culture and environment was first described by Hamilton et al as the "integration of cultural change initiatives and facility design to achieve a transformational outcome that supports the mission, vision, values, and culture of an organization."2(p41) The goal of joint optimization is to positively impact the quality of the patient and the provider experience through transformative change in the organizational cultural values, the design of the physical setting, the assumptions and expectations, and the artifacts and symbols in the environment. The authors indicated that "if an existing organizational structure and culture are simply transferred unchanged to a new setting, the opportunity for optimization is forfeited."2(p41)

Back to Top | Article Outline

Moving In: The Ultimate Change Project

There is always a sense of excitement about opening a new building, with the move of patients and providers prefaced with months of preparation and training. Moving in is clearly the ultimate change project. Everything changes-the environment of care; workflow processes; skills and competencies of the providers; team organization and communication patterns; distribution of supplies, equipment, meals, and medications; and, in some organizations, the organizational culture and philosophy of care. Moving into a new building requires years of visioning, planning, and preparing not only for the new building but also for the day-to-day operations. The logistics of the actual move is but one critical component among many that must be planned. Staff must be prepared to play together in a "new sandbox." Planning must be focused on staffing, process changes, working in the new environment, and educating staff in new skills and competencies resultant from the changes in the environment and organization of workflow/patient flow.

Back to Top | Article Outline
Staffing Changes

Although the design of most new hospitals is planned using existing staffing levels and future staffing needs of new programs and services, the new facility often demands a new analysis of staffing needs and reallocation of staffing resources. Expansion of existing services or the addition of new patient types requires a projection of anticipated full-time equivalents to care for these patients and a recruitment plan that ensures an available workforce upon opening. Not only must existing staff be oriented to the new facility, but also plans must also be developed for the orientation of newly hired staff, whose competencies must be assessed and validated. New staff must also have an indoctrination of organizational culture to ensure that the vision and values of the organization are upheld.

Staffing and patient assignment methods may be altered because of the changes in the configuration of the new building. The length of hallways, the number of beds on a unit, the mix of patient types, and changes in patient acuities may require different staffing plans or patient assignment loads. The usual organizational structure may also change, requiring a different ratio of nurse managers to staff or a transition to a different management model using clinical nurse leaders, nurse practitioners, or other advanced practice nursing models in lieu of the traditional hierarchical models.

Back to Top | Article Outline
Educating the Staff for the New Care Environment

Moving to a new facility creates tremendous staff educational needs that must be planned, budgeted, and executed. Typically, education focuses on 5 general areas: (1) new clinical competencies needed; (2) life safety training in the new environment; (3) training on the new equipment; (4) workflow exercises in the new setting, or "sandbox familiarization"; and (5) general orientation for work in the new building for leaders, staff, and physicians. When the new facility is an addition to an existing facility, with some staff remaining behind, additional communication and education must be planned for those "left behind." The importance of this consideration was recently documented in a study of "movers" (nurses moving to a new facility) and "stayers" (those left behind in the older facility). Berry and Parish3 reported that movers rated job satisfaction, job stress, and perceptions of service quality significantly more positively than the stayers did. Stayers need to have planned communication telling them what (if anything) will be done to update their work environments and how their workflow processes will change with some specialties moving to the new building. Additional education may need to enhance their knowledge and skills in caring for different types of patients if these changes are made.

Back to Top | Article Outline
Population-Based Training

The actual design of patient units may create changes in the mix of patient types that were not experienced in the previous facility, which necessitates population-based training. As an example, bariatric patients may have been previously integrated among all patient types, but in the new facility, they may be cared for in a specific unit designed for these patients, which requires expansion of some nurses' knowledge competencies and skill sets. In older facilities, patients needing telemetry were housed in a specifically designated "telemetry unit," but in many new facilities, all acute care units and patient rooms are designed to be capable of telemetry. This physical change requires that all acute care nurses advance their knowledge and skills in interpretation of telemetry tracings and the activation of the appropriate intervention for patients with abnormal cardiac rhythms. Integration of patient types in the acute care setting or the separation of patient types into specifically designated units may require additional skill sets or certifications for some nurses. Whereas population-based training must be provided for some nurses, life safety training must be planned for all providers.

Back to Top | Article Outline
Life Safety Training

The change in the design of the physical care environment requires that all providers receive training in how emergency responses will be performed in the new setting. Providers must be oriented to the new floor plan, where emergency supplies and equipment will be stored, the location of medical gas controls, and the team response behaviors expected in the new environment. Mock drills before the move assures that staff are educated and can implement a rapid response to any emergency. Patient safety and evacuation routes must also be reviewed so staff know how to execute these plans in the new facility.

Back to Top | Article Outline
Equipment Training

Most new building projects include the purchase of new equipment, including new patient beds, safe patient mobilization devices, and overbed tables, monitors, and other medical devices, each with its own set of complexity and alarms. All staff must be scheduled for training on all new equipment specific to their unit, with competencies appropriately documented. In addition, any changes made in existing or new computerized documentation systems must be carefully reviewed with staff to ensure that they are competent in operationalizing the new systems immediately upon moving into the new building.

Back to Top | Article Outline
Workflow Exercises

Training sessions must be planned for unit-based staff to rehearse how the work of patient care might be altered in the new setting. Older units often had multibed patient rooms, but new facilities are often designed with only single-occupancy patient rooms. This one change significantly alters workflow processes and lengthens the distances that nurses must walk from patient to patient. Discussions among staff need to occur with decisions made about workflow changes. The new building may also include new models of supply and distribution of meals and nutritional supplements for patients, clean linen, patient supplies, and equipment procurement and storage. As an example, new units often have automated supply distribution centers and medication storage and preparation areas with computerized documentation and billing for the supply item or medication, which is retrieved by the nurse for the patient. This seemingly simple change creates complex changes in workflow processes for staff who must be oriented to these new delivery, documentation, and billing processes.

Older units lack adequate storage areas for soiled linen, trash, and dirty equipment. Newer units require space to be provided for the proper storage and disposal of these items and other potentially infectious wastes, so staff will need to accommodate to new routines of disposing of dirty and used equipment, supplies, and linen.

Back to Top | Article Outline

Managing the Change

Planning the change processes required for moving into the new building must be initiated at least 2 years in advance of the move to ensure that all required education, training, and competency validations are accomplished. A project management chart such as GANTT or other project scheduling tool with milestone markers is useful in tracking progress in recruitment and staffing plans, process changes, environmental and equipment planning and procurement, staff education, and move-in sequencing. A steering committee with multidisciplinary representatives should be formed to plan, execute, monitor, and evaluate the planning process for move in. Each specific department and unit can create their own planning committee to address the needs of their own department and staff.

Operational planning is only one part of the strategic initiative of moving into a new facility. The hospital's leadership must also create a vision and cultural values that will guide professional behaviors and patient care within the new building and among those who stay behind in the existing facility. This cultural planning is critical to achieve the joint optimization of merging culture and environment that fundamentally transforms the philosophy of care, workflow processes, expected and valued behaviors, and the total experience for patient and provider. A healing environment is more than new marble flooring, wood finishes on walls, comfortable new lobby furniture, attractive artwork, and green plants and flower gardens. A real healing environment shows the power of place, the power of change, and the gift of care givers.4

There is significant evidence now that "place" impacts human behavior and health,5,6 and the power of "change" can optimize the healing environment experience by merging culture and place. A healing environment embodies the mind, body, and spirit of patient and family in space that honors the family and their unique support of the patient. A healing environment also honors the unique gift of each care giver who gives his/her self, in the present moment, to promote healing of others and oneself. The hospital's leadership must ensure the joint optimization of culture and environment to ensure a positive synergy and experience for patient and provider.

Back to Top | Article Outline


1. Porter-O'Grady T, Malloch K. Quantum Leadership. Sudbury, MA: Jones & Bartlett; 2007.

2. Hamilton DK, Orr RD, Raboin WE. Organizational transformation: a model of joint optimization of culture change and evidence-based design. Health Environ Res Des J. 2008;1(3):40-60.

3. Berry LL, Parish JT. The impact of facility improvements on hospital nurses. Health Environ Res Des J. 2008;1(2):5-13.

4. Huelat BJ, Wan TTH. Healing Environments: What's the Proof. Alexandria, VI: Medezyn; 2007.

5. Ulrich RS, Zimring C, Zhu X, et al. A review of the research literature on evidence-based healthcare design. Health Environ Res Des J. 2008;1(3):61-125.

6. Ulrich R, Zimring C, Joseph A, Quan X, Choudhary R. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004.

Cited By:

This article has been cited 2 time(s).

Journal of Nursing Administration
Moving Into a New Hospital Strategies for Success
Ecoff, L; Thomason, T
Journal of Nursing Administration, 39(): 499-503.

Journal of Nursing Administration
Lessons Learned From the Design Experience
Stichler, JF
Journal of Nursing Administration, 39(): 305-309.

Back to Top | Article Outline

© 2009 Lippincott Williams & Wilkins, Inc.